Tapeworm Diseases

Tapeworm Diseases

 

Definition

Tapeworms are a group of parasitic worms that live in the intestinal tracts of some animals. Several different species of tapeworms can infect humans. Tapeworm disease or cestodiasis occurs most commonly after eating raw or undercooked meat or fish that contains the immature form of the tapeworm.

Description

Tapeworm infections pose a serious public health problem in many less developed countries due to poor sanitation conditions. The disease is most common where livestock, such as cattle and pigs, are raised in areas where human feces are not disposed of in a sanitary manner. Another common source of human tapeworms are certain species of freshwater fish. Tapeworm infections tend to occur more frequently in areas of the world where the people regularly eat raw or undercooked beef, pork, or fish. Persons of all ages and both sexes are susceptible to tapeworm infection, but children are generally not exposed until they are old enough to begin eating meat or fish.
Tapeworm infections in humans are less common in industrialized regions of the world, although German public health experts reported in 2003 that the rate of these infections is higher in Europe than the official statistics indicate. Travel to areas where tapeworm infections are more common and immigration of people from these areas serve as new sources of the parasite. Infected persons are often unaware of the presence of adult tapeworms in their intestinal tract, as they may have no obvious symptoms of infection. Some tapeworms can live in an infected person for over 10 years if diagnosis is not made and treatment is not administered.
In addition to the typical infection caused by eating undercooked meat or fish, people may also be directly infected by ingesting tapeworm eggs shed by the adult worm. This type of tapeworm infection can lead to a condition referred to as cysticercosis, in which the larvae continue to develop within tissues other than the intestinal tract. One of the most serious forms of this disease occurs when the tapeworm larvae infect the central nervous system, a disease referred to as neurocysticercosis. In contrast to a typical tapeworm infection, which may not be associated with symptoms, neurocysticercosis is a serious condition that may cause seizures and is potentially life-threatening.

Causes and symptoms

Several species of tapeworm can infect people. The two most common species are the pork tapeworm (Taenia solium) and the beef tapeworm (Taenia saginata). Improperly treated human sewage may be used to fertilize pastures or crops. Pigs or cattle become infected by grazing in contaminated pastures or drinking water contaminated with tapeworm eggs from human feces. The pea-sized larvae of these tapeworms are deposited in certain tissues of the body of infected pigs and cattle, including the muscles. The infection is then transmitted to people when raw or undercooked meat containing tapeworm larvae is consumed. The immature tapeworm develops into the adult form in the human intestine and may remain there for many years if not identified and treated.
The Taenia tapeworms attach to the intestinal walls but cause only mild inflammation at the site of attachment. As a result, most tapeworm carriers show no symptoms (asymptomatic) and usually become aware of the infection only after noticing tapeworm segments in their feces. Segments of the beef tapeworm may spontaneously pass through the anus causing a noticeable sensation. Mild gastrointestinal symptoms, such as nausea or abdominal pain, can occur in infected individuals. In rare cases where the tapeworm segments migrate into the appendix, pancreas, or bile duct, there may be a sudden onset of severe abdominal discomfort.
Cysticercosis is a potentially serious complication of Taenia solium infection in which the larvae develop outside the intestinal tract. This type of infection is less common and occurs following accidental consumption of tapeworm eggs released from the adult worm. These eggs initially are localized in the anal area, but they may also contaminate the fingers or other parts of the body. Infection can occur in the person harboring the adult tapeworm or in other people with whom that individual comes in contact. The tapeworm larvae may develop in various tissues throughout the body. The most serious clinical problems occur when the larvae develop in the central nervous system (neurocysticercosis), potentially causing seizures and other neurological problems. An important aspect of this type of infection is that poor hygiene on the part of the individuals harboring an adult tapeworm can lead to an infection in an individual who may never consume meat. This is a particular problem if infected individuals are employed as food handlers.
Another important tapeworm that may infect people is the fish tapeworm (Diphyllobothrium latum). This is a frequent human intestinal parasite in many areas where raw freshwater fish is consumed. Human infection with the fish tapeworm is referred to as diphyllobothriasis. Feces from infected hosts or raw sewage contaminates a fresh water source. Tapeworm larvae are initially ingested by freshwater crustaceans and then are eaten by fish. Human infection occurs when a person consumes raw fish contaminated with the tapeworm larvae. Adult tapeworms then develop in the human intestinal tract.
Most infections with the fish tapeworm are not associated with symptoms. The tapeworm causes little damage to the lining of the intestine. Infected individuals may report diarrhea, fatigue, weakness, or sensation of hunger more commonly than uninfected individuals. One problem unique to this tapeworm is that it may compete with the host for absorption of vitamin B12 from the small intestine, causing the person to become deficient in this vitamin and leading to a condition called pernicious anemia.
Two smaller species of tapeworms may also infect people. The dwarf tapeworm (Hymenolepis nana) is a common infection throughout the world that can be passed from one person to another. Transmission is usually the result of inadvertent ingestion of tapeworm eggs from feces eliminated by infected individuals. As a result, infection with this tapeworm is encountered most frequently in children, the developmentally disabled, and psychiatric patient populations. Abdominal pain that is not localized to any particular area is the most common complaint. Patients may experience loose bowel movements or diarrhea with mucus, but bloody diarrhea is rare.
Another small tapeworm capable of infecting people is the rodent tapeworm (Hymenolepis diminuta). Rats, mice, and other rodents are the usual hosts for the adult tapeworm (definitive host), but humans can become infected following accidental consumption of insects containing tapeworm larvae. Meal worms or grain beetles that infest cereal, flour, or dried fruit are the most likely source of infection. Most human infections are not associated with symptoms, although some individuals report headaches, anorexia, nausea, and diarrhea.

Diagnosis

Identification of tapeworm segments or eggs in a stool sample is necessary for diagnosis of an adult tapeworm infection. In many cases, a tentative diagnosis may be made on the basis of a patient's description of short chains of tapeworm segments in their stool. Further evaluation is recommended to determine the actual species involved since infection with Taenia solium is potentially more serious due to the added risk of cysticercosis. Whenever possible, tapeworm segments should be carefully collected in water or salt solutions, using strict precautions to avoid contamination. Stool examination should be performed in a laboratory having experience in the diagnosis of intestinal parasites. It is recommended that at least three stool samples be collected on alternate days to increase the likelihood of being able to make an accurate diagnosis.
Although the general appearance of tapeworm segments from the two Taenia species is quite similar, trained laboratory personnel can detect distinct differences between the beef and pork tapeworms when samples are examined under a microscope. Tapeworm segments and eggs from the fish tapeworm and the dwarf tapeworm have characteristic appearances that allow accurate differentiation from the Taenia species of worms. Other diagnostic procedures may be necessary when cysticercosis is suspected. Blood samples from an infected individual are collected to look for the presence of antibodies against the tapeworm larvae. In 2004, researchers isolated an antigen diagnostic for cysticercosis alled GP50. In cases in which infection of the central nervous system is present, advanced imaging tests, such as computed tomography scans and magnetic resonance imaging (MRI), may be necessary to determine the exact location of the tape-worm larvae within the body.
Ultrasound imaging is also being used as of 2003 to diagnose tapeworm infections. Because of the recent rise in immigration and travel, clinicians in developed countries are seeing more patients with tapeworms. The World Health Organization (WHO) has developed standardized sets of ultrasound images to help doctors recognize the signs of a parasitic infection. In some cases, ultrasound allows the doctor to see the tapeworm directly.

Treatment

Effective treatment of tapeworm infections involves administering compounds that are toxic to the adult worm. Many of the early treatments were also somewhat toxic to the patient, so treatment was often quite an ordeal. Newer medications are much more easily tolerated and are highly effective in eliminating the parasite from the body. It is important, however, to completely eliminate the head and neck regions of the tapeworm, as the entire worm can regenerate from these parts.
One treatment that has been in use since the early 1960s is niclosamide (Niclocide). This drug is poorly absorbed from the digestive tract and rapidly kills tapeworms upon exposure. It has been shown to be effective against Taenia species and the fish tapeworm, but treatment of the dwarf tapeworm (Hymenolepis nana) may require a more prolonged treatment schedule. Side effects reported with niclosamide are infrequent and typically mild. When present, side effects may include nausea, abdominal discomfort, vomiting, diarrhea, light-headedness, and skin rash. This medication should be taken in the morning on an empty stomach. The tablets are chewed thoroughly and swallowed with water. For young children, the tablets may be pulverized and mixed with water. Patients are allowed to eat two hours after treatment. Recommended dosage is 2 grams for adults and about half this for children.
Another oral medication that has been shown to be 95% effective in the treatment of tapeworm infections associated with both Taenia and Diphyllobothrium latum species is praziquantel (Biltricide). Side effects reported for praziquantel are mild and appear to be short-lived. They include nausea, abdominal pain, itching, sore joints, and muscle pain.
It is recommended that follow-up stool samples be examined at one month and three months after treatment has been completed. Treatment can be considered successful if no eggs are present in several stool samples. It should be noted that the tapeworm medications do not kill the tapeworm eggs when they kill the adult worm, so the potential for infection with eggs still exists as the dead worm segments are passed. Proper personal hygiene in individuals receiving treatment will greatly reduce this potential.
Cases of neurocysticercosis, where larvae have developed in the central nervous system, may also be treated with praziquantel or albendazole. If the patient is treated promptly, damage to the central nervous system will be minimized.
As of late 2003, researchers in developing countries are working on a vaccine for pigs to help control neurocysticercosis; however, the vaccine is not likely to be available for several years.

Prognosis

When confined to the intestinal tract, tapeworms cause minimal damage to their human host. Once the diagnosis of an intestinal tapeworm infection has been made, prognosis following treatment with niclosamide or praziquantel is good. The worms can be eliminated from the intestines with oral treatment, and there are usually no residual side effects. Serious problems from tapeworm infections occur when tapeworm eggs are consumed and the larvae localize in tissues outside the digestive tract (cysticercosis). Prompt diagnosis and treatment of this condition is necessary to prevent permanent damage to the central nervous system and other internal organs. In fact, cysticercosis is becoming increasingly recognized as an important cause of severe neurologic disease in the United States. Untreated cases of cysticercosis have the rare potential to be life-threatening; in some cases, liver transplantation has been necessary to save the patient's life.

Key terms

Cestodiasis — Parasitic infection caused by the presence of adult tapeworms of the class Cestoda within the intestinal tract. Infection is caused by accidental consumption of tapeworm larvae.
Cysticercosis — Parasitic infection caused by the presence of immature tapeworm larvae (cysticerci) that have developed outside the intestinal tract. Infection is caused by accidental consumption of tapeworm eggs.
Diphyllobothriasis — Parasitic infection caused by the presence of tapeworms from the Diphyllobothrium genus, such as the fish tapeworm (Diphyllobothrium latum).
Hymenolepiasis — Parasitic infection caused by the presence of tapeworms from the Hymenolepis genus, such as the dwarf tapeworm (Hymenolepis nana) or the rodent tapeworm (Hymenolepis diminuta).
Neurocysticercosis — Parasitic infection caused by the presence of immature tapeworm larvae within the central nervous system.
Pernicious anemia — Type of anemia caused by a deficiency in vitamin B12.
Taeniasis — Parasitic infection caused by the presence of tapeworms from the Taenia genus, such as the pork tapeworm (Taenia solium) or the beef tapeworm (Taenia saginata).

Prevention

The best way to prevent infection with tapeworms is to eliminate the exposure of livestock to the tapeworm eggs by properly disposing of human feces. The next best strategy is to thoroughly cook or freeze all meat and fish before it is eaten to prevent consumption of live tapeworm larvae in infected samples. Larval cysts in pork and beef are killed by moderate temperatures of 150°F (65°C) or if frozen for at least 12 hours. Proper cooking of freshwater fish could also eliminate the possibility of human infection with the fish tapeworm. Freezing fresh fish for 24 hours will also kill the larval form.
People who raise sheep or horses should have these animals checked regularly by a veterinarian and dewormed if necessary.
The Centers for Disease Control and Prevention (CDC) recommends that people traveling abroad should wash their hands with soap and water before handling food; should wash and peel all raw vegetables and fruits before eating; and should drink only bottled or boiled water, or carbonated drinks in cans or bottles.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Cestodes (Tapeworms)." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Periodicals

Garcia, H. H., A. E. Gonzalez, C. A. Evans, et al. "Taenia solium Cysticercosis." Lancet 362 (August 16, 2003): 547-556.
Richter, J., C. Hatz, and D. Haussinger. "Ultrasound in Tropical and Parasitic Diseases." Lancet 362 (September 13, 2003): 900-902.
Schnieder, T. "Parasitological Risks—From Animal Husbandry to Food and Humans." [in German] Deutsche tierartzliche Wochenschrift 110 (August 2003): 326-328.
Sorvillo, Frank J., et al. "Cysticercosis-related deaths, California." Emerging Infectious Diseases March 2004: 465-470.
"Taenia Solium Antigen Diagnostic for Cysticercosis Characterized." Drug Week March 12, 2004: 111.

Organizations

American Veterinary Medical Association (AVMA). 1931 North Meacham Road, Suite 100, Schaumburg, IL 60173-4360. http://www.avma.org.
Centers for Disease Control and Prevention. 1600 Clifton Rd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311. http://www.cdc.gov.

Other

Centers for Disease Control and Prevention (CDC) Fact Sheet. "Cysticercosis." http://www.cdc.gov/ncidod/dpd/parasites/cysticercosis/factsht_cysticercosis.htm.